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1111 , <br /> ELECTRICAL PERMIT APPLILATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> — - 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: -, / (Cite i7) bi L` 1/e BUILDING AREA: a 5-0e) sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: ®SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL <br /> ELECTRICAL APPLICATION:INFORMATION:& DESCRIPTION:OF WORK <br /> CONTRACT PRICE OF WORK:$ 5, O-9 . oc ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: C- l4,d(t- i lac -t`i,) e_fe , <br /> a-11 dA{ /y/a5 i,v� L41 u/ , e (a e j�C Fri t / ))Qkr c-( , /• 1 new <br /> bAl‘'fj/ <br /> .04 THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECTreALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope: IN Service ® Feeder 0 Circuits-#:?O 0 Complete Re-wire <br /> LOW VOLTAGE WORK? ® NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom 0 Thermostat 0 Audio 0 Secure Access 0 Security System <br /> ❑ Fire Alarm-Installations under this permit only include electrical wiring rough-in of the system.An additional <br /> Fire Alarm Permit is required for review of device location and installation approval. <br /> ❑Other(List All): <br /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: a NO 0 YES--See Below&Pg.2 <br /> ❑ By checking this box, I am stating that I have read and understand all of WAC 296-46B-900,selected the specific reason on page 2 <br /> of this application(see next page),AND Plan Review is NOT required because I meet all of the following sub sections that do not <br /> See Page 2 require Plan Review. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO OYES-See Below&Pg.3 <br /> 0 Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale,or lease <br /> without the proper electrical licensing and certification,or exemption. By checking this box, I am stating that I have completed and <br /> See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. <br /> • ;CONTACT.INFORMATION <br /> OWNER NAME: A you //a a/(L / TTENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET ? Ce I u4"/ b11- 4 ✓� <br /> �� <br /> t 22 CITY r✓�l�� 7+ STATE UI I f�� <br /> ZIP � c <br /> 9O <br /> OWNER PHONE: 3cl ?j c.b OWNER EMAIL: <br /> CONTRACTOR NAME: Si/l/Q c f nem <br /> CONTRACTOR ADDRESS: STREET C) 5 cs%f- /CEJ ./170 /?/a i L <br /> CITY 0 fly N7 D)1. STATE IN ZIP /W v�T <br /> / it JTOR EMAIL: <br /> mar ` <br /> CONTRACTOR LIC.#(REQUIRED): S� Ii7ecTY OF EVERETT BUSINESS LIC.#(RUIRED) JjS <br /> _ , „,„ _ , ? <br /> PRIMARY CONTACT: ❑OWNER rzr CONTRACTOR D OTHER(PleaseSpecify) <br /> CONNTACT NAM / CG <br /> CONTACT PHONE: 3 ( ,9 fj <br /> r1 c A/6,-rj CONTACT EMAIL: !'1,ne, y- <br /> tax <br /> 12 > �t'4i CT u G C- <br /> AGREEMENT.•I hereby certify that I have read and examined this application and know the same to be true and correct. All provision f laws and rdinances governing this <br /> type of work will be completed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or <br /> local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the work for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> / /, E iaoa -6(1o <br /> Owner/Aut orized Agent '•nature Date (Revised 1/11/2019) Page 1-Application <br />